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Fernandez Valledor A, Moeller CM, Rubinstein G, Oren D, Rahman S, Baranowska J, Lee C, Lorenzatti D, Righini FM, Lotan D, Sayer GT, Uriel N. Durable left ventricular assist devices as a bridge to transplantation: what to expect along the way? Expert Rev Med Devices 2024:1-12. [PMID: 39169616 DOI: 10.1080/17434440.2024.2393344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 07/28/2024] [Accepted: 08/13/2024] [Indexed: 08/23/2024]
Abstract
INTRODUCTION The scarcity of donors coupled with the improvements in left ventricular assist devices (LVAD) technology has led to the use of LVAD as a bridge to transplantation (BTT). AREAS COVERED The authors provide an overview of the current status of LVAD BTT implantation with special focus ranging from patient selection and pre-implantation optimization to post-transplant outcomes. EXPERT OPINION The United Network for Organ Sharing 2018 policy amendment resulted in a significant reduction in the number of LVADs used for BTT in the US. To overcome this issue, modifications in the US allocation policy to consider factors such as days on device support, age, and type of complications may be necessary to potentially increase implantation rates.
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Affiliation(s)
- Andrea Fernandez Valledor
- Division of Cardiology, Advanced Cardiac Care, Columbia University Irving Medical Center, New York, NY, USA
| | - Cathrine M Moeller
- Division of Cardiology, Advanced Cardiac Care, Columbia University Irving Medical Center, New York, NY, USA
| | - Gal Rubinstein
- Division of Cardiology, Advanced Cardiac Care, Columbia University Irving Medical Center, New York, NY, USA
| | - Daniel Oren
- Division of Cardiology, Advanced Cardiac Care, Columbia University Irving Medical Center, New York, NY, USA
| | - Salwa Rahman
- Division of Cardiology, Advanced Cardiac Care, Columbia University Irving Medical Center, New York, NY, USA
| | - Julia Baranowska
- Division of Cardiology, Advanced Cardiac Care, Columbia University Irving Medical Center, New York, NY, USA
| | - Changhee Lee
- Division of Cardiology, Advanced Cardiac Care, Columbia University Irving Medical Center, New York, NY, USA
| | - Daniel Lorenzatti
- Division of Cardiology, Montefiore Medical Center. Albert Einstein College of Medicine, New York, NY, USA
| | - Francesca Maria Righini
- Division of Cardiology, Department of Medical Biotechnologies, University of Sienna, Toscana, Italy
| | - Dor Lotan
- Division of Cardiology, Advanced Cardiac Care, Columbia University Irving Medical Center, New York, NY, USA
| | - Gabriel T Sayer
- Division of Cardiology, Advanced Cardiac Care, Columbia University Irving Medical Center, New York, NY, USA
| | - Nir Uriel
- Division of Cardiology, Advanced Cardiac Care, Columbia University Irving Medical Center, New York, NY, USA
- Division of Cardiology, Weill Cornell Medicine, New York, NY, USA
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Widhalm G, Aigner P, Gruber B, Moscato F, Moayedifar R, Schaefer AK, Dimitrov K, Zimpfer D, Riebandt J, Schlöglhofer T. Preoperative anatomical landmarks and longitudinal HeartMate 3 pump position in X-rays: Relevance for adverse events. Artif Organs 2024. [PMID: 39105573 DOI: 10.1111/aor.14837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 07/08/2024] [Accepted: 07/22/2024] [Indexed: 08/07/2024]
Abstract
BACKGROUND Left ventricular assist device (LVAD) malposition has been linked to hemocompatibility-related adverse events (HRAEs). This study aimed to identify preoperative anatomical landmarks and postoperative pump position, associated with HRAEs during LVAD support. METHODS Pre- and postoperative chest X-ray measures (≤14 days pre-implantation, first postoperative standing, 6, 12, 18, and 24 months post-implantation) were analyzed for their association with HRAEs over 24 months in 33 HeartMate 3 (HM3) patients (15.2% female, age 66 (9.5) years). RESULTS HM3 patients with any HRAE showed significantly lower preoperative distances between left ventricle and thoracic outline (dLVT) (25.3 ± 10.2 mm vs. 40.3 ± 15.5 mm, p = 0.004). A ROC-derived cutoff dLVT ≤ 29.2 mm provided 85.7% sensitivity and 72.2% specificity predicting any HRAE during HM3 support (76.2% (>29.2 mm) vs. 16.7% (≤29.2 mm) freedom from HRAE, p < 0.001) and significant differences in cardiothoracic ratio (0.58 ± 0.04 vs. 0.62 ± 0.04, p = 0.045). Postoperative X-rays indicated lower pump depths in patients with ischemic strokes (9.1 ± 16.2 mm vs. 38.0 ± 18.5 mm, p = 0.007), reduced freedom from any neurological event (pump depth ≤ 28.7 mm: 45.5% vs. 94.1%, p = 0.004), and a significant correlation between pump depth and inflow cannula angle (r = 0.66, p < 0.001). Longitudinal changes were observed in heart-pump width (F(4,60) = 5.61, p < 0.001). CONCLUSION Preoperative X-ray markers are associated with postoperative HRAE occurrence. Applying this knowledge in clinical practice may enhance risk stratification, guide therapy optimization, and improve HM3 recipient management.
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Affiliation(s)
- Gregor Widhalm
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Philipp Aigner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Bernhard Gruber
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Francesco Moscato
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria
- Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Roxana Moayedifar
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Kamen Dimitrov
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Julia Riebandt
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Thomas Schlöglhofer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria
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Zijderhand CF, Peek JJ, Sjatskig J, Manintveld OC, Bekkers JA, Bogers AJJC, Caliskan K. Influence of the Outflow Graft Angular Position on the Outcomes in Patients With a Left Ventricular Assist Device. ASAIO J 2024:00002480-990000000-00464. [PMID: 38595102 DOI: 10.1097/mat.0000000000002189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024] Open
Abstract
This study aimed to explore the potential impact of the angular position of the outflow graft on thromboembolic events and aortic valve regurgitation in people with a left ventricular assist device (LVAD). We analyzed contrast computed tomography (CT) data of patients with LVAD implantation between 2016 and 2021. Three-dimensional reconstructions of the outflow graft and aortic arch were performed to calculate the horizontal (azimuth) angle and vertical (polar) angle, as well as the relative distance between the outflow graft, aortic valve, and brachiocephalic artery. Among 59 patients (median age 57, 68% male), a vertical angle ≥107° correlated significantly with increased cerebrovascular accidents (hazard ratio [HR]: 5.8, 95% confidence interval [CI]: 1.3-26.3, p = 0.022) and gastrointestinal bleeding (HR: 3.4, 95% CI: 1.0-11.2, p = 0.049) during a median 25 month follow-up. No significant differences were found between the vertical angle and aortic valve regurgitation or survival. The horizontal angle and relative distance did not show differences regarding clinical adverse events. This study emphasizes the importance of the LVAD outflow graft angular position to prevent life-threatening thromboembolic events. This study suggests the need for prospective research to further validate these findings.
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Affiliation(s)
- Casper F Zijderhand
- From the Thoraxcenter, Department of Cardiothoracic Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Jette J Peek
- From the Thoraxcenter, Department of Cardiothoracic Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Jelena Sjatskig
- From the Thoraxcenter, Department of Cardiothoracic Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Olivier C Manintveld
- Thoraxcenter, Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Jos A Bekkers
- From the Thoraxcenter, Department of Cardiothoracic Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Ad J J C Bogers
- From the Thoraxcenter, Department of Cardiothoracic Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Kadir Caliskan
- Thoraxcenter, Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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Rodenas-Alesina E, Brahmbhatt DH, Rao V, Salvatori M, Billia F. Prediction, prevention, and management of right ventricular failure after left ventricular assist device implantation: A comprehensive review. Front Cardiovasc Med 2022; 9:1040251. [PMID: 36407460 PMCID: PMC9671519 DOI: 10.3389/fcvm.2022.1040251] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 10/18/2022] [Indexed: 08/26/2023] Open
Abstract
Left ventricular assist devices (LVADs) are increasingly common across the heart failure population. Right ventricular failure (RVF) is a feared complication that can occur in the early post-operative phase or during the outpatient follow-up. Multiple tools are available to the clinician to carefully estimate the individual risk of developing RVF after LVAD implantation. This review will provide a comprehensive overview of available tools for RVF prognostication, including patient-specific and right ventricle (RV)-specific echocardiographic and hemodynamic parameters, to provide guidance in patient selection during LVAD candidacy. We also offer a multidisciplinary approach to the management of early RVF, including indications and management of right ventricular assist devices in this setting to provide tools that help managing the failing RV.
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Affiliation(s)
- Eduard Rodenas-Alesina
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
- Department of Cardiology, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Darshan H. Brahmbhatt
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Vivek Rao
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
| | - Marcus Salvatori
- Department of Anesthesia, University Health Network, Toronto, ON, Canada
| | - Filio Billia
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
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Salna M, Ning Y, Kurlansky P, Yuzefpolskaya M, Colombo PC, Naka Y, Takeda K. The Impact of Intrapericardial versus Intrapleural HeartMate 3 Pump Placement on Clinical Outcomes. J Chest Surg 2022; 55:197-205. [PMID: 35478180 PMCID: PMC9178299 DOI: 10.5090/jcs.21.148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/24/2022] [Accepted: 03/02/2022] [Indexed: 11/30/2022] Open
Abstract
Background The integrated design of the HeartMate 3 (Abbott Laboratories, Chicago, IL, USA) affords flexibility to place the pump within the pericardium or thoracic cavity. We sought to determine whether the presence of a left ventricular assist device (LVAD) in either location has a meaningful impact on overall patient outcomes. Methods A retrospective cohort study was conducted of all 165 patients who received a HeartMate 3 LVAD via a median sternotomy from November 2014 to August 2019 at our center. Based on operative reports and imaging, patients were divided into intrapleural (n=81) and intrapericardial (n=84) cohorts. The primary outcome of interest was in-hospital mortality, while secondary outcomes included postoperative complications, cumulative readmission incidence, and 3-year survival. Results There were no significant between-group differences in baseline demographics, risk factors, or preoperative hemodynamics. The overall in-hospital mortality rate was 6%, with no significant difference between the cohorts (9% vs. 4%, p=0.20). There were no significant differences in the postoperative rates of right ventricular failure, kidney failure requiring hemodialysis, stroke, tracheostomy, or arrhythmias. Over 3 years, despite similar mortality rates, intrapleural patients had significantly more readmissions (n=180 vs. n=117, p<0.01) with the most common reason being infection (n=68/165), predominantly unrelated to the device. Intrapleural patients had significantly more infection-related readmissions, predominantly driven by non-ventricular assist device-related infections (p=0.02), with 41% of these due to respiratory infections compared with 28% of intrapericardial patients. Conclusion Compared with intrapericardial placement, insertion of an intrapleural HM3 may be associated with a higher incidence of readmission, especially due to respiratory infection.
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Affiliation(s)
- Michael Salna
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Yuming Ning
- Center for Innovation and Outcomes Research, Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Paul Kurlansky
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Melana Yuzefpolskaya
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Paolo C Colombo
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Yoshifumi Naka
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Koji Takeda
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
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Schlöglhofer T, Aigner P, Migas M, Beitzke D, Dimitrov K, Wittmann F, Riebandt J, Granegger M, Wiedemann D, Laufer G, Moscato F, Schima H, Zimpfer D. Inflow cannula position as risk factor for stroke in patients with HeartMate 3 left ventricular assist devices. Artif Organs 2022; 46:1149-1157. [PMID: 34978722 PMCID: PMC9305857 DOI: 10.1111/aor.14165] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 12/10/2021] [Accepted: 12/23/2021] [Indexed: 01/06/2023]
Abstract
Background A relation between the left ventricular assist device inflow cannula (IC) malposition and pump thrombus has been reported. This study aimed to investigate if the pump position, derived from chest X‐rays in HeartMate 3 (HM3) patients, correlates with neurological dysfunction (ND), ischemic stroke (IS), hemorrhagic stroke (HS) and survival. Methods This analysis was performed on routinely acquired X‐rays of 42 patients implanted with a HM3 between 2014 and 2017. Device position was quantified in patients with and without ND from frontal and lateral X‐rays characterizing the IC and pump in relation to spine, diaphragm or horizontal line. The primary end‐point was freedom from stroke and survival one‐year after HM3 implantation stratified by pump position. Results The analysis of X‐rays, 33.5 (41.0) days postoperative, revealed a significant smaller IC angle of HM3 patients with ND versus no ND (0.1° ± 14.0° vs. 12.9° ± 10.1°, p = 0.005). Additionally, the IC angle in the frontal view, IS: 4.1 (20.9)° versus no IS: 13.8 (7.5)°, p = 0.004 was significantly smaller for HM3 patients with IS. Using receiver operating characteristics derived cut‐off, IC angle <10° provided 75% sensitivity and 100% specificity (C‐statistic = 0.85) for predicting IS. Stratified by IC angle, freedom from IS at 12 months was 100% (>10°) and 60% (<10°) respectively (p = 0.002). No significant differences were found in any end‐point between patients with and without HS. One‐year survival was significantly higher in patients with IC angle >10° versus <10° (100% vs. 71.8%, p = 0.012). Conclusions IC malposition derived from standard chest X‐rays serves as a risk factor for ND, IS and worse survival in HM3 patients.
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Affiliation(s)
- Thomas Schlöglhofer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria.,Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Philipp Aigner
- Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria.,Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Marcel Migas
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Dietrich Beitzke
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Kamen Dimitrov
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Franziska Wittmann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Julia Riebandt
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Marcus Granegger
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Dominik Wiedemann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Günther Laufer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Francesco Moscato
- Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria.,Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Heinrich Schima
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria.,Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria
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